Anesth Analg 1999;89:1576
© 1999 International Anesthesia Research Society
CASE REPORTS
An Unexpected Complication During Laparoscopic Herniorrhaphy
Christopher P. Harkin, MD*,
Eiler W. Sommerhaug, MD
, and
Kathrin L. Mayer, MD
Departments of
*Anesthesiology and
Surgery, University of California, Davis, Sacramento, California
Address correspondence and reprint requests to Christopher P. Harkin, MD, Department of Anesthesiology, PSSB, Suite 1200, 4150 "V" Street, Sacramento, CA 95817. Address e-mail to cpharkin{at}ucdavis.edu
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Introduction
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Laparoscopic totally extraperitoneal (TEP) inguinal herniorrhaphy is an increasingly accepted alternative to the traditional open or laparoscopic transabdominal preperitoneal hernia repair (1). In fact, the TEP herniorrhaphy may be the preferred operation for patients with recurrent or bilateral hernias (2,3). However, this surgical technique is associated with the standard complications of inguinal hernia repair and, rarely, with potentially serious complications (4–6). We present a case in which an unexpected and life-threatening complication occurred during TEP.
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Case Report
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A 44-yr-old, ASA physical status I, 81-kg man presented for bilateral TEP hernia repair. A right-sided pantaloon hernia was identified and reduced, and a small direct hernia was identified on the left. The patient was not taking any regular medications, but did intermittently use loratadine and a triamcinolone inhaler to treat seasonal allergies. The patient had had an appendectomy in the distant past.
After premedication with midazolam, anesthesia was induced with sodium thiopental, fentanyl, and rocuronium, IV, and the trachea was intubated without difficulty. Anesthesia was maintained with isoflurane in 60% air and 40% oxygen and with intermittent doses of fentanyl and rocuronium.
The pelvic preperitoneal space was expanded with a balloon spacemaker and was insufflated with carbon dioxide (CO2) at 15 mm Hg pressure. Laparoscopic ports were placed into the preperitoneal space. The patient was hemodynamically stable, and his lung were easily ventilated with delivered tidal volumes of 600 mL, a respiratory rate of 8 bpm, and a peak inspiratory pressure of 18 cm H2O. His oxygen saturation was 99% on an inspired oxygen concentration of 42%, and ETCO2 was 32 mm Hg. Inspection of the inguinal floor was performed bilaterally, and the same findings as described above were found. The hernia sac was dissected from the underlying structures, and the sac was reduced. Fifty-five minutes into the procedure, the patient’s tidal volumes suddenly decreased to 320 mL, and the peak inspiratory pressures and ETCO2 increased to 34 cm H2O and 64 mm Hg, respectively. The surgeons were advised of the changes in the ventilatory variables and insufflation of CO2 was ceased. The patient’s chest was auscultated during manual ventilation, and no breath sounds were heard on the right side.
Immediately, the fraction of inspired oxygen (FIO2) was increased to 1.0. The endotracheal tube was examined, and although it had not advanced, it was pulled back 1 cm. A 14F-suction catheter was passed through the endotracheal tube from which no mucous material was aspirated. Manual ventilation after either of these interventions did not produce breath sounds over the right chest. The patient remained hemodynamically stable throughout this period. An arterial blood gas and a chest radiograph were obtained. The patient’s pH was 7.32, PCO2 was 61 mm Hg, and PO2 was 117 mm Hg. The chest radiograph revealed a large right pneumothorax with a deep sulcus sign and a shift of the mediastinum to the left (Fig. 1). Because of these radiographic findings and lack of improvement in the ventilatory variables, a chest tube was placed in the anterior-axillary line, fourth intercostal space. During chest-tube placement, a rush of gas was noted but not analyzed. No air leak was present following the reexpansion of the right lung or throughout the postoperative period. With the chest tube in place, equal breath sounds were auscultated over both sides of the chest. The procedure continued with placement of an 8 cm x 12-cm mesh over both inguinal floors. For the remainder of the procedure, the patient was hemodynamically stable and had slow restoration of normal ventilatory variables. The trachea was extubated in the operating suite. A repeat chest radiograph in the postanesthesia care unit showed no pneumothorax or gas below the diaphragm (Fig. 2).
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Figure 1. Chest radiograph revealing a large right pneumothorax with an accompanying deep sulcus sign and shift of the mediastinum to the left. Large arrow: edge of collapsed right lung, small arrow: deep sulcus sign.
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Figure 2. Repeat chest radiograph in the postanesthesia care unit showing chest-tube, resolution of the right pneumothorax and deep sulcus sign.
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Of note, the patient did not have any subcutaneous emphysema intraoperatively or throughout the postoperative period. 
-1-Antitrypsin levels were normal, and after cardiothoracic surgical evaluation, a chest computerized tomography (CT) scan was recommended 1 mo postoperatively to exclude possible bullous disease. The chest tube was removed on postoperative Day 2, and the patient was discharged the following day. The follow-up chest CT scan revealed no pulmonary blebs or bullae.
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Discussion
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The anesthetic management and complications of intraabdominal laparoscopic procedures has been extensively discussed (7). Pneumothorax is a rare but serious complication of such procedures. However, pneumothorax as a complication of laparoscopic TEP herniorrhaphy is unexpected. The surgical procedure confines CO2 insufflation and laparoscopic port placement to the extraperitoneal space. After dissection, a large prosthetic mesh is placed to cover the hernia defect and the inguinal floor. Advantages of this procedure include low morbidity and recurrence rates, and less risk of intraperitoneal contamination, infection, adhesions, and intraabdominal organ injuries compared with the transabdominal preperitoneal laparoscopic or open procedure (2,3,5).
Patients under general anesthesia may develop a pneumothorax for multiple reasons, such as barotrauma, lung bullae rupture, or needle insertion into the pleural cavity. Although a ruptured bleb or bulla may have been the etiology of this pneumothorax, the lack of a persistent air leak and a negative chest CT scan for bullous disease lowers the likelihood of their being the cause. In this patient, the pneumothorax was likely a complication of CO2 insufflation into the preperitoneal space. This pneumothorax presented with a sudden increase in ETCO2 and peak-inspiratory pressures. After the FIO2 was increased to 1.0, after suctioning and manipulating the endotracheal tube and increasing ventilation without improvement, a chest radiograph revealed a right pneumothorax.
Ferzli et al. (6) described in the surgical literature two patients who developed pneumothoraces during TEP herniorrhaphy. The first patient desaturated and had an increased ETCO2 at the completion of the procedure. A chest radiograph revealed bilateral pneumothoraces and pneumomediastinum. The second patient also desaturated and had an increased ETCO2, but developed massive subcutaneous emphysema in addition to a right pneumothorax and pneumomediastinum. Both patients remained hemodynamically stable, and changes in ventilatory pressures were not discussed. Furthermore, these pneumothoraces occurred insidiously; thus, neither patient had a chest tube placed. The authors kept these patients tracheally intubated and allowed the CO2 to be reabsorbed and ventilated off. Repeat chest radiographs revealed that both pneumothoraces had resolved.
In contrast, our patient did not develop subcutaneous emphysema, and the chest radiograph revealed a large right pneumothorax with left mediastinal shift. Because of these chest radiograph findings and the fact that ventilatory pressures and ETCO2 did not decrease with cessation of insufflation or other treatment modalities, a chest tube was placed. Because of the urgency of the procedure, the gas evacuated from the pneumothorax was unfortunately not analyzed. We contend that the gas in the pleural space was CO2, because a pneumothorax produced by a ruptured bulla or bleb would not produce a significant rise in end-tidal or arterial CO2 (8). Moreover, our patient did not have an air leak after reexpansion of the right lung or throughout the postoperative period, and the chest CT scan failed to document pulmonary bullous disease.
We agree with others that a high CO2 insufflation pressure (15 mm Hg) may cause a pneumothorax (6) and/or subcutaneous emphysema (6,9). How the CO2 diffused into this patient’s pleural space from the preperitoneal space is still in contention. Most likely, the CO2 enters the retroperitoneal space and passes along tissue planes into the pleural space (10). This theory is supported by data showing that CO2 diffusion into the body is greater during extraperitoneal than intraperitoneal CO2 insufflation (11,12). Management of presumed or confirmed pneumothorax during TEP herniorrhaphy requires cessation or reduction of CO2 insufflation, discontinuation of nitrous oxide administration and hyperventilation, and maintenance of hemodynamics as necessary. Tube thoracostomy may not be necessary unless the patient is hemodynamically unstable or has a compromised ventilatory status, because CO2 diffuses rapidly from the body. Other authors who have treated patients with pneumothoraces during laparoscopic fundoplication recommended keeping these patients tracheally intubated and increasing their peak end-expiratory pressure, thereby decreasing the likelihood of need to perform a tube thoracostomy (13). Moreover, pneumothorax may be prevented by maintaining CO2 insufflation pressures below 10 mm Hg and keeping the insufflation time to less than two hours (5,6). This case reinforces the importance of vigilance, including monitoring breath sounds, ETCO2, SpO2, and ventilatory pressures, using nitrous oxide judiciously, adjusting ventilation, and maintaining communication between the anesthesiologist and surgeon.
In summary, we present a case of a healthy man undergoing laparoscopic TEP inguinal herniorrhaphy who developed a large right pneumothorax with left mediastinal shift. This was presumably produced by the high CO2 insufflation pressures into the extraperitoneal space and CO2 passing retroperitoneally into the pleural space. Controlling these insufflation pressures and maintaining vigilance can prevent this sequelae or the need for chest-tube placement for lung reexpansion.
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References
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Accepted for publication August 30, 1999.
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Introduction
Case Report
